i033 Biologic dose reduction: the physician's perspective

Abstract

Disease activity guided dose optimisation of bDMARDs in RA has been shown to be safe and to result in substantial cost savings compared to usual care continuation. Data supporting this are derived from randomised trials including the DRESS study, and several systematic reviews. Of note, for axial spondylarthropathies or psoriatic arthritis, the body of evidence in considerably less. However, implementation of bDMARD dose tapering is lacking in clinical practice. As dose adjustments are treatment decision that are made in shared decision making between physicians and patients in the consultation room, increasing uptake of these strategies hinge on optimising behaviour of physicians and patients, and their interaction. We will focus in this presentation on the physician's perspective. Of note, variation between practices of rheumatologist, as well as qualitative and quantitative studies strongly suggest that characteristics of the health care provider have much more influence on implementation results than do patient characteristics such as beliefs. In general, protocol adherence by health care providers is determined by a complex array of knowledge, attitude and barriers. The most important of these are: the knowledge how to proper use a treat-to-target tapering strategy; a positive attitude towards tapering (including intrinsic motivation and several important incentives and de-centives), and finally practical barriers including for example time constraints and electronic health record reminders. A few studies have assessed the effects of interventions to improve adherence to dose optimisation strategies. These intervention targeted all three domains of knowledge, attitude and barriers, and large effects could be achieved by a complex multimodal intervention, known as academic detailing. However, just dissemination of a protocol is not enough to achieve substantial adaptation of these treatment strategies. In summary, clinicians should be aware of the current state of art in bDMARD tapering, and that a positive attitude towards this approach can rationally be endorsed. Clinicians should realise that they have a large impact on final treatment decisions made in shared decision making with patients, and finally that several barriers may prevent them to achieve maximal personal effectiveness.